Dinah, ClinkShrink, & Roy produce Shrink Rap: a blog by Psychiatrists for Psychiatrists. A place to talk; no one has to listen.
All patient vignettes are confabulated; the psychiatrists, however, are mostly real.
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Tuesday, November 22, 2011

Consider Meagan’s dilemma. She is a 30-year-old, separated store clerk who is now living in a shelter for battered women. Meagan was severely abused by her husband, and now takes care to conceal her whereabouts, lest he try to find her. Using the internet connection at her public library, Meagan finds a website that deals with issues of battering, including help for those women (or men) who want to obtain a restraining order against the abusing spouse. Meagan would like to participate in the online discussion, but is afraid to use her full name. She suspects that her husband “tracks” websites like this, and that he might retaliate violently if he sees her name. She chooses to use a pseudonym and posts a letter on the website.

Is Meagan justified in concealing her online identity? I would not hesitate in saying that she is. I would take the same position when someone faces reprisals from a totalitarian regime, such as protesters in Iran and Egypt; or in the case of a “whistleblower” who wants to expose a public danger online, without risking being fired.

But absent such compelling dangers to life, limb or livelihood, I am generally opposed to the use of pseudonyms or anonymous postings on the internet. Of course, there are exceptions beyond those I have noted, and each case must be considered individually. But as a rule, I believe that the burden of justification should be on the individual who chooses to conceal his or her identity, and that website monitors ought to be exceedingly selective in accepting unsigned or pseudonymous letters.

I am speaking, of course, from the perspective of a psychiatric physician who is used to posting my blogs with “full disclosure”—not only of my name, but also of my potential conflicts of interest. (Having retired recently from clinical practice, and having no financial connections to pharmaceutical companies, my only “conflicts” these days are the ones a psychoanalyst would explore—but for those who want to delve, my disclosure statement is viewable on the Psychiatric Times website, at:

The issue of personal disclosure bears on one reason I am opposed to anonymous blogs and postings: the general public has no way of determining what, if any, concealed agenda or conflicts of interest the anonymous blogger or commentator may have. I find this issue especially pertinent when the unidentified person launches a personal attack against someone who is identified by name, profession, etc. As a psychiatrist who blogs fairly often on both the Psychcentral and Psychiatric Times websites, it is especially upsetting when an alleged “health care professional” posts a highly critical, anonymous comment, in response to an article or essay I have written. In my view—barring some of the exceptional circumstances I outlined earlier—a physician, nurse, psychologist, social worker or other health care professional has no business concealing his or her identity when voicing an opinion on a professionally-related topic, especially when taking aim at a colleague. I consider such “drive-by flaming” both professionally irresponsible and ethically unjustifiable. It is also downright rude and inconsiderate—what my dad would have called “a cheap shot”!

So why do so many health professionals post anonymously, or sign their emails as “MiffedDoc” or “Irateinternist”? I think that, in many cases, it is a simple wish to avoid embarrassment or discovery, either by patients or by colleagues. And, in my view, that excuse simply doesn’t cut it. My understanding of professional ethics is that you should be willing to stand behind anything you say in a professional context, and that your audience has a right to know who you are and who may be standing behind you—the American Medical Association? The Scientologists? The government of Iraq? Readers Digest?

Sure, there may be exceptions to this rule. I can imagine a health care professional who is revealing an extremely sensitive personal issue—let’s say, a problem with substance abuse—who does not want to disclose his or her name. Yet he or she believes that the message has important public health implications. So, Dr. X may be posting a message saying, “As a physician who has had a problem with alcohol abuse, I would urge all my colleagues to report obvious substance abuse problems among their colleagues to the appropriate authorities...” OK—anonymity in this context is understandable, Doc.

By the way, I also believe we have an ethical responsibility to avoid attacking another person’s character, engaging in gratuitous insults, casting aspersions, or just plain being rude! (For more on “internet ethics”, please see my essay originally posted on the Psychiatric Times website, and also viewable at: http://www.jeffpearlman.com/todays-cnn-com-column-3/). A good rule of thumb, which I try (not always successfully) to live by: if you wouldn’t be comfortable saying something to a person face-to-face, think twice about saying it in an anonymous internet message. (You might just run into that individual at a conference!).

Only when self-disclosure poses a great personal risk are we justified in hiding behind anonymity. In short, all of us have a responsibility not only to tell the truth, but to tell the truth about who we are.

****************

Ronald Pies MD is Professor of Psychiatry and Lecturer on Bioethics & Humanities at SUNY Upstate Medical University, Syracuse, NY; and Clinical Professor of Psychiatry at Tufts University School of Medicine, Boston. The views expressed here are solely his own.

Note: Dr. Pies does not reply to unsigned, anonymous, or pseudonymous messages, except when the justification for anonymity is clear.

25
comments:

It's curious that the first response to Dr. Pies's thoughtful article is an anonymous spam item. Can this be deleted? It may contain viruses.

I basically agree, but not entirely. I have no problem answering thoughtful remarks from pseudonymous physicians or others but I do not like the feeling of repeated dialogues with anonymous people who will not even choose a pseudonym. We have many people here who use pseudonyms and often they have suffered something or from someone to the extent that they do not want to reveal their identity. I respect their wishes.

Over time we all recognize that each of these people has a unique personality and that lends itself to responses that are both warmer and more accurate. It is as if we know each other to that little extent, and I respect their wish to not use their names.

Even before this was put up I had been considering not answering any post that is simply Anon. I and the Shrink Rappers (and others) reveal our identity. If some cannot even choose a pseudonym why should I engage with them? It feels like talking to a hooded person.

I agree with many of your points, and I also dislike reading personal attacks, but feel your concept of the non-anonymous blog represents an ideal world where prejudice and gossip do not exist. I would not comment on a mental health blog in which I had to reveal my identity. You did specifically say "a physician, nurse, psychologist, social worker or other health care professional", but my recollection is that about half of the people posting on this site are patients, not health care professionals. I am one of the patients and could not and would not post if I had to reveal my identity. There IS prejudice against mental illness. I am a second year teacher on a one year contract and can't risk the possibility of not being hired next year due to postings to a mental health blog. However, I do use the same pseudonym each time I post which is linked to my Google account, and I post truthfully and try to respect the other people who post here. As a retired clinician you have a lot less to lose than someone in the job market who might be stigmatized by mental illness. I think the extreme example of Meagan's physical danger from her abusive husband is clear, but not the only case that makes a pseudonym acceptable. Would I be hired in a field of 300 candidates for a teaching position if the school knew I had been hospitalized for 3 weeks because I was psychotic? I highly doubt it.

@OP - I don't disagree with most of what you wrote. However, you only addressed from a clinician's perspective. I can think of plenty of reasons why a mental health patient might prefer anonymity. Do I really need to list every reason a person in psychiatric treatment might prefer to keep that information confidential? The psychiatrist provider does not have anything to gain by keeping the fact that he is a psychiatrist confidential. The patient, on the other hand....is 180 degrees on the other end.

@Jesse - are you more comfortable, then, with a "handle" (ex: sadgirl25) as opposed to an "Anon?" Sadgirl25, or even "Michael" is just as anonymous - so why, then, so opposed to use of the term "Anon?" Consistency?

First, I'd like to thank Dr. Miller and Shrink Rap for the invitation to post my essay. I also want to thank those who already have taken the time to write. I will wait for a few more responses to come in, and will plan to reply to some general issues raised.

I do understand that some individuals prefer not to use their actual name, and I certainly respect that choice when a patient's privacy or safety is the main concern. I do recognize that physicians and patients do not start from an equal "power base", and so, I do apply a different standard when it comes to online anonymity--i.e., I can rarely justify it when used by health care professionals, but can understand it when some patients wish to post anonymously.

@Anon, yes, I'm much more comfortable with a "handle." The two reasons are that within the given Blog it is possible to "@Henry" in the same way you just addressed me, but when there are ten or many more Anons it is very difficult to have a dialogue, which I think is one of the more valuable functions of Shrink Rap. It is the "Rap" after all! I think that Anon comments with multiple Anons just creates confusion.

The second reason is that for those who post regularly here there is a bit of a camaraderie that develops - I think, "oh, here is another post by Sunny, or Sideways, and have some idea of how those people think.

It makes dialogue much better, and I find too many Anons off-putting. Like meeting a hooded Anon in a dark alley. It is very easy to choose some form of name for this blog and it does not compromise true anonymity at all.

I said it on some other posting, but I went by anon a few times because I didn't understand how to give myself a name on here when I didn't have a google account and what is an Open ID? etc.

I have mental illness and a history of severe abuse, and I talk about these things anonymously so people get that point of view, and can keep it in mind when appropriate. Otherwise, I would say nothing. I try hard to pass for normal in my community.

I agree that when people are anonymous, they are more likely to behave badly, and I hate that.

@OP - I appreciate that you hear the distinction between provider and patient anonymity. I really think it's a significant one.

@Jesse - I hear what you are saying as far as simplicity in comments - you are right, there are many anons and it does get confusing on posts that have many comments. On other blogs I have seen posters use Anon1, Anon2, etc.

That said, finding many "anons" is off-putting for you. Using a false name is off-putting for me. I don't mean this facetiously, but -- which is stranger, given that this is, after all, an internet forum? If a patient said to you, "I don't like speaking with many anonymous people who I don't actually know anyway," or "I don't want to use a false name and identity" - which would you think more (or less!) odd, even pathological? Think about it.

I do hear that you can develop rapport, etc with a name you see often. But....what if I don't want to develop a rapport with you, or to be known by you? Or Dinah? Or Roy? Or a particular poster who posts all the time and whose opinions I find irritating? Part of (one of many) the distinction between a blog and a support group, etc, is that posters can be anonymous. If the blog writers find me (or anyone else) distasteful or offensive or even just annoying, they can always block my IP address. I'm not your patient. Perhaps I do not want to be known by you. (I mean no offense to you in particular, Jesse. In fact, I am a huge fan, and wish you had a blog of your own! But I don't think that negates my point.)

CatLover, I see you figured it out! I think all you do is click on the little dot that says "Name/URL" and as soon as you do that a box appears in which you can put a name. I'm going to try that right now using the name DarkAlley. Let's see if it works!

Ironically, tonight there was a long document placed on our psychiatric society's listserv--- it was written by an attorney for the APA and warns about the potential dangers of social media for psychiatrists, and plays into the fears of 'bad things might happen if you do this.'

I think many psychiatrists view blogs as landmines, and being anonymous is a way of being protected from all the bad things that we're told will happen if your dumb enough to write on a blog.

I also agree that anonymity leads people to say things they wouldn't and shouldn't, and I have felt that having my name on my blog reminds me that it's not my personal diary and I need to be careful what I say. My two co-bloggers worried at first and would only blog under the condition of anonymity. When nothing awful happened, they came out. And then there was our book...makes is a bit hard to stay dark.

Thanks for joining us Ron. And if you need cheap term life insurance, the first commenter is not anonymous.

I think the main issue is that in writing comments on blogs, one needs to be honest and considerate of other posters and of the blog keeper. While anonymity often accompanies rude remarks, there is not a 100% correlation. It is the rudeness that is the underlying issue, not anonymity. As Jesse has pointed out, I agree that pseudonyms make a dialogue easier. I use a pseudonym, but I hope that I am in fact, still anonymous.

Dr. Ron Pies has little to lose as a retired practitioner making comments about the practice of his profession. He might feel differently if instead, he were posting about his personal mental and physical health, and personal relationships, especially if his mental health history included hospitalization and psychosis.

I am happy to read Dr. Ron Pies added comment that he does understand the patient desire to not disclose his or her name. There is prejudice against mental illness. That is a fact in our society. This is not just an issue of personal safety for the patients.

I am a patient and also a second year teacher on a temporary contract, who will need to job hunt again next summer. With hundreds of people competing against me for each job in fall, 2012, I can't risk the hiring administration having access to personal mental health information. Would a potential employer hire someone who was involuntarily hospitalized due to psychosis if selecting from a field of 350 candidates for the job?

My recollection is that about 50% of the posters on this blog are patients as I am. Using a pseudonym allows honesty and full disclosure rather than prevents it for me, and I assume for others. If I had to post my real name, I simply could not post at all.

One of the people on the blog I respect the most is actually Rob. I do not always agree with him, but if you click on his name it takes you straight to his website. I would have thought he'd be scared of losing patients because of his views. But apparently he's not, and I applaud his decision to advertise his controversial views of psychiatry (and ADHD on his website for his pediatric office) all while using his actual name. At least he is a doctor who does not need to hide behind "MiffedDoc" or "IrateInternist."

I love Alone's Last Psychiatrist blog, but I wonder how quickly he would shut up if he actually had to post while using his real name. If he was ever "outed", I could see him losing a ton of patients...though I also think he might gain a lot too. I honestly don't know how I would feel if I found out that my shrink is Alone. I told my friend, "Could you imagine if this guy was your shrink?!"

I have a lot of respect for a doctor who can openly share his or her professional views without hiding behind anonymity. Especially because doctors are science types, so they put a lot of emphasis on being able to back up their claims with sources and evidence. If they aren't afraid of the loss of patients, I could see them cringing at the possibility of professional ostracism. I've actually wondered if Keith Ablow faced any professional backlash for his views on transgendered people and Cher's daughter turned son. Are there other psychiatrists who turn their children from him when he walks down the street or pretend not to see him?

My main points were - @OP - I appreciate that you are able to recognize the differnece between anonymous posting as a mental health provider vs. patient. I think the discrepancy is hugely significant.

@Jesse - I hear you about the confusion. I have been on other blogs where people sometimes reply as anon1, anon2, anon who hates shrinks, etc and that alleviates (some) confusion.

That said, you find anons "off-putting" - but perhaps I find assuming a false name for myself off-putting. Think for a minute if a patient of yours said to you that he finds anonymous posts by internet users that he will never actually know off-putting, vs. a patient who said to you, I find it really uncomfortable to take on a false name and use that as a consistent identity. Which is less odd, really?

I do understand your point about getting to "know" people with handles, etc. That said...perhaps I don't want to be known by you, or by Dinah, or by Roy, or by Dr. Ron Pies or with another patient commenter who uses a consistent handle. Maybe I am not looking to develop a relationship of any kind with you, or maybe I find certain other users to be annoying - maybe I don't like what they have to say or their predictable twist on everything...maybe I don't want them or you or Dinah "knowing" me in the same way that I "know" them.

This is a internet blog...it is not a therapist's office. The anons are not your patients, and perhaps they are not seeking out a relationship with you. I don't mean this personally toward Jesse - I happen to be a huge fan and wish you had a blog of your own. However, I am not your patient (or Dinah's or Roy's. Nor am I a colleague or friend or peer of the more common posters here): I am not looking for a relationship or a camaraderie with you.

@Jen, I think your points are excellent, and actually agree with them. That there is in some way an identification with its "Oh, here is another post by Jen or by Jane or by whomever is simply the result of recognizing that I had read fifteen posts by that person and so have begun to become familiar with his or her style, ideas. It is a form of shorthand.

My point is almost entirely in terms of when there is a complex subject being discussed and there are many, many Anons. I want to address something that occurred six comments before but find it difficult to do so. If the Blogger listed each post with a number (Anon posted in comment #6) that would help, or perhaps the first Anon would be Anon1, the second Anon2. I value the dialogue!

So my point is about communication. I totally respect any desire for anonymity whether from the psychiatrists here (like Sideways) or from anyone else.

More thinking about anonymity here and my feelings about it. I just finished reading (minutes ago) Isaacson's biography of Steve Jobs, and I am certain Steve would not have commented on Shrink Rap as an Anon (of course, maybe he did!). But I am puzzled as to what it really is that bothers me about it. My own explanation that it has to do with communication does not sound complete. Certainly the Anons bother me the most when they are somewhat hostile.

I need to give this more thought, but stick with the observation that I am in general more comfortable answering a question when the commenter has chosen some identifier.

But as human behavior is much of what we discuss here, the reasons that people choose Anon are interesting to me. One person noted that choosing a false identity may be distasteful. There are good reasons to use just Anon and that certainly is one of them.

@Jesse, I'm glad you posted that because the last post you wrote about communication being your main point did not ring true to me either; it sounded, surface, in some way. I may be way off.

I think you made a good point about the reasons why someone chooses to use Anon being interesting. For that matter, for the most part I use an anon because I don't like the idea of creating a false identity and a "handle" as such feels two decades in my past - holdover from AOL days. On the other hand, there are also times when I use anon because the topic is too close to home - it feels too vulnerable to express an opinion on a "hot" topic or a personal experience to this slew of (anon and non-anon) posters. Irrational paranoia - do they know me? Will someone recognize the story I'm telling?

I personally don't use anon with the intent to be snarky or hostile, though it is clear that others do, and that is another reason.

Since today is Thanksgiving, I'll simply thank everyone who has written in, and I appreciate that this is a sensitive and complex topic, particularly for folks who are in a very vulnerable position. Perhaps more later...but for today, thanks, everybody!

Now there's an irony...somehow, my last message got posted under "Anonymous"! Maybe my subconscious is talking? Or is it just that I can't figure out how to post correctly? Well...I'll ponder that over the turkey!--Regards, Ron Pies MD

Most posting on the internet in fact is anonymous. If you are on twitter, that usually calls for some identification at least maybe your name. I post frequently on news sites and all posters overall use a screenname to post. If your commments are such that they are from a particular person of interest per se, one owes it to disclose their names or some identification of personhood. I disagree that someone who posts to a community of battered women should be required to post a name and certainly it is obvious that feelings are involved and thus one righteously can post under an assumed pseudonym or other created name.

If people use their real names or not I still don't know them. So, it doesn't matter to me either way.

On the other hand, it would have been really nice if my former psychiatrist had had a blog published under his own name where I might have had a sense of who he was as a person - then, I would have known to go somewhere else. But, then again had he used his name he might have been careful about what he said and still I might not have had a true sense of who he really is.

Others have pointed out the risks of using your real name are quite different between an established professional and a psychiatric patient. It's always easier to take risks when there isn't all that much to risk. I am impressed, though, by the professionals who challenge the party line under their own names - that takes guts and I think it will eventually lead to some positive changes.

Thanks to all who have contributed to this discussion! I have learned quite a bit from several commentators. In particular, I have a better understanding of why some individuals in psychiatric treatment, or with psychiatric illnesses, would choose to conceal their identity when posting on the internet.

I also agree that the issues of vulnerability and power often differ for an established professional with a secure position; and someone, say, who faces reprisals or job loss if an irate boss is offended by the employee's online posting.

All that said, I would add that MDs, including many psychiatrists, also take risks when they post blogs or articles under their real names (as they should, in general). Psychiatrists working for an HMO, clinic, or medical school may face a hostile reaction from the corporate or academic higher-ups, after posting a very controversial piece. In some cases, MDs may even receive threats from readers who are angered by what the doctor has said. (Having published some "signed" blogs on health care reform and gun control, I can tell you that some of the enraged responses left me fearful for my own safety!). Incidentally, I have always signed anything I write on a professional topic--not just since I retired from clinical practice.

I do agree with one reader, who suggested that the most important issue is whether the blog or letter is civil, polite, and respectful. My real argument is with "colleagues" who post extremely insulting, ad hominem attacks on other professionals, and refuse to provide their own names! If you care to see what I mean, try logging on to some of the debates featured on various health care websites. You can cut the anonymous vitriol with a knife!

I will plan to end my comments here, but again, with my thanks to Dinah and Shrink Rap, and to all those who have written in!

I'm wondering if there's a generational gap here, because I generally take some semblance of anonymity on the internet as SOP. You don't necessarily take a pseudo-name because you're hiding something, you take it because it's the internet and that's what you do. I've also seen it pointed out that many internet names are more identifying than a real name, especially for somebody who is active online. It wouldn't take somebody very long or much effort to figure out my real identity from my Google handle or blog.. but then again, if I Google my real name, I don't find myself, I just find a bunch of other people with the same real name, and my name may not be bizarre, but it's not absurdly common either. A much greater percentage of what I find is me when I Google my handle than when I Google my "real" identity.

Plenty of people are perfectly rude while using their real names, online or off.

Honestly, for the most part I don't care who somebody is or what their real-life credentials are. Most of the time when I see somebody citing credentials, it's in lieu of an actual point. The way I see it, those credentials (if they're real, which I don't usually have any way of verifying online) just make it completely inexcusable that they can't make a decent point. Generally when I see somebody legitimately mention their real-life profession or credentials, it's in a more anecdotal context of personal experience than a statement of expertise. There are various people across different internet forums I consider experts on particular topics. I think many have some professional link to their topic of choice, but it's usually secondary to simple obsessive interest.

Jen, you never reminisce about '90s AOL? Granted, most chats these days go with the IRC tradition of "/me" rather than the ::action:: actions of AOL.. but I still carry a fondness for the general framework of early AOL.